Divine Word College of San Jose NURSING DEPARTMENT

A CASE STUDY About Exacerbation of Chronic Obstructive Pulmonary Disease

Concept: NCM 103 Respiratory Area: Medical Ward Batangas Regional Hospital Batangas City Date September 12-16, 2011

Presented By: Group II Leader: Alvin Bonilla Members: Amira Alorro Philip Luis Benoza Cindy Joy Dela Cruz Ruth Sanchez Mary Abegail Tesalona

Presented To: AGNES B. DOTE, RN, MAN Clinical Instructor/ Coordinator Bernadeth Aguila RN, MAN Clinical Instructor Sofia Sandra R. Moraleja RN, MAN Nurse Training Officer

I. INTRODUCTION Our client XXY is a 60 years old resident of Purok 5, Lipa City, Batangas. He was a former mechanic and welder. He worked there at 32 years and stopped on year 2000 because he was hospitalized at Marry Mediatrics Medical Center and was diagnosed of having COPD. He is living with his beloved wife and siblings. He is a cigarette smoker and uses a pack or 20-30 sticks of cigarette a day. The Global Initiative for Chronic Obstructive Lung Disease(GOLD) has defined chronic obstructive pulmonary disease (COPD) as a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases(GOLD,2008,p.2). This updated definition is a broad description that explains COPD and its signs and symptoms. Although previous definitions have categorized emphysema and chronic bronchitis as a types of COPD, this was often confusing because most patients with COPD, present with overlapping signs and symptoms of these two distinct disease processes. People with COPD commonly become symptomatic during the middle adult years, and the incidence of the disease increases with age. Although certain aspects of lung function normally decrease with age-for example, vital capacity and forced expiratory volume in second (FEV1), COPD accentuates and accelerates these physiologic changes. This case study aims to learn more and gain knowledge about COPD so we will be able to develop and improve the clients condition through the use of nursing process, nursing management and different nursing intervention. II. BIOGRAPHIC DATA Name of Patient: PATIENT XXY Address: Purok 5, Lipa City, Batangas Gender: Male Age: 60 years old Civil Status: Married Date of Birth: November 10, 1950 Place of Birth: Tipakan, Lipa City, Batangas Educational Attainment: High School Graduate Occupation: Former mechanic and welder Religion: Roman Catholic Chief Complaint: Difficulty of breathing Primary Medical Diagnosis: Exacerbation Of COPD Physician: Date of Admission: September 8, 2011 at around 3:45pm

III. HEALTH HISTORY A. History of Present Illness It was Tuesday afternoon when the client experience difficulty of breathing. He was brought at Batangas Regional Hospital on September 8, 2011 at exactly 3:45pm. He was pale, weak and irritable. His respiration ranges from 27-30cpm. He was dyspneic with production and secretion of sputum with productive cough. B. Past Health History On 1990 he was diagnosed of having PTB and successfully treated within 6 months. On the year 2000 was first time our client hospitalized at Marry Mediatric Medical Center and diagnosed of having COPD. He was stopped in working. According to our client he is always brought to the hospital several times per year. But this year (2011) it is his third time to be hospitalized at Batangas Regional hospital and he was diagnosed to have exacerbation of chronic obstructive pulmonary disease. From year 2000-2011 he only consumes 5-10 sticks of cigarettes per day. C. Family History There is no history of COPD but there is a history of stroke.

IV. PSYCHOLOGICAL HEALTH A. Coping Pattern Whenever the client has problems, his family is always there to support her if there are problems encountered regarding financial and conflicts. Analysis: Coping may be described as dealing with changes successfully or unsuccessfully. It is cognitive and behavioral effort to manage external or internal demands that are approved as exceeding resources of the person.(Fundamentals of Nursing Kozier& Erb pg. 1068) Interpretation:

The client has a good relationship to his families and friends.

B. Interaction Patterns
The client expresses his feelings and thoughts to his wife and friends. For him it is essential it is increase trust and bonding and for them to know his feelings. He is a kind of person who does not blame others whatever happens. Analysis: This includes the ways of exposing affection of love, sorrow, anger, to note significant family members in persons life and openness of communication within a family member. (Fundamentals of Nursing Kozier pg. 193) Interpretation: The client is open and very close to his family and friends. This is essential to improve social life.

C. Emotional Pattern
If the patient gets angry he tells it frankly to his family and relatives in good manner in order to maintain good relationship to them. Analysis: Emotional pattern includes thoughts and actions that relieve emotional distress. It does not improve the situation, but the person often feels better. (Fundamentals of Nursing Kozier pg. 147) Interpretation: Good relationship to his family is very important to him: He believed that doing good communication is the best way to have good relationship to them.

D. Family Copping Pattern

When he encountered problems he tells it to his wife. Analysis: The families have functions that are important in how individual family members meet their needs and maintain their health. The family provides the individual with the necessary environment for development and social interactions. (Lippincott Williams and Wilkins of Nursing page 30) Interpretation: Being open to his wife is a good quality to solve any problems.

E. Cognitive Pattern
The client finished elementary and high school. He was attentive in school. He can speak and understand English and Filipino.
Analysis: The families have functions that are important in how individual family members meet their needs and maintain their health. The family provides the individual with the necessary environment for development and social interactions. (Lippincott Williams and Wilkins of Nursing page 30) Interpretation: The client can read and understand Filipino and English.

F.Self Concept
He loves and accepts who he is physically. Analysis: Self-concept involves all of the perception that is appearance, values, beliefs that influence behavior and that are referred to when using the word I or me. It is over mental image of oneself. (Fundamentals of Nursing, kozier and Erbs page 957) Interpretation: He accepts things easily.

G. Sexuality
He is contended of being a male and accepts responsibility of being a father. Analysis: Sexuality is an individually expressed and highly personal phenomenon whose meaning evolves from life experiences. Satisfying or normal sexual expression can generally be described as whatever behaviors give pleasure and satisfaction to the adults involved, without treat of coercion or injury to self or others (Kozier & Erbs Fundamentals of Nursing page 1029) Interpretation: He is satisfied with what he had now.

V. Socio-cultural Health A. Cultural Pattern

The client instructed his siblings to obey or respect elders and everyone. They have family reunion yearly. They love eating Filipino foods. Analysis: Cultural Pattern refers to cultural beliefs that we are practicing. Culture is a non physical trait such as beliefs, attitudes and customs that is shared by a group. (Kozier and Erbs Fundamentals of Nursing page206) Interpretation:Their family believes that respecting others is a good quality that Filipinos must have. They love eating Filipino dishes.

B. Significant Relationship
The patient significant others give their best to support and give his strength to face his problem. Analysis: Significant relationship is the clients support systems in times of stress what affects the client illness has on the family and whether family problems are affecting the client. (Kozier and Erbs Fundamentals of Nursing page 268) Interpretation: His significant others serve as his backbone in every moment of his life especially his family.

C. Recreation
The patient loves playing softball and billiards and he spend most of his times by smoking at least 10-30 sticks of cigarettes per day. Doing these made him more relaxed and it became his hobby. He also loves drinking liquors occasionally. Analysis: Recreation or hobbies are an exercise activity and tolerance hobbies and other interest and vocations. (Kozier and Erbs Fundamentals of Nursing page 263) Interpretation: Clients recreation and hobbies are not good for his health even though it decreases stress. Those hobbies are risk factors for developing much kind of diseases.

D. Environment:
The client live in a simple but a clean house together with his beloved family. They have dogs. They can move freely and comfortably in their house. Analysis: Environment is all of the conditions, circumstances and influences surrounding and affecting the development of a person. Physical environment consider the natural boundaries, sizes and population density, types of dwells and incidence of crime and vandalism. (Kozier and Erbs Fundamentals of Nursing page 201) Interpretation: He is living in a healthy place. They love pets.

E. Economic
He has a enough salary for his family. He is prioritizing foods. Analysis: Economic status identifies the clients ability to pay or afford medical care or health care in order to ensure his or her own health stability. Interpretation:They have slightly enough money to buy and support basic needs.

VI. SPIRITUAL HEALTH A. Religious Beliefs & Practices

He is a Roman Catholic. They attend mass occasionally and he prays every night. Analysis: Spiritual and religious belief can signifies that affect health behavior. It also refers to that part of being human that seeks meaningfulness through intra, inter, and transpersonal connection. Spirituality generally involves a belief in a relationship with some higher power, creative, divine being or infinite source of energy. (Kozier and Erbs Fundamentals of Nursing page 1042) Interpretation: The client has faith in God.

B. Value & Valuing

He valued most and keeps treasured all the things he received from others. He also valued of taking care of his family. Analysis: Values are freely chosen enduring belief or attitude about the worth of a person, object idea or action. It is important because it influences decision and actions including nurses ethical decision making. (Kozier and Erbs Fundamentals of Nursing page 69) Interpretation: He appreciates all the things that he receives from his friends and family.

VII. ACTIVITIES OF DAILY LIVING Activities of Daily Living 1. Nutrition Before Hospitalization The patient eats 3x a day and he usually eats rice, meat, vegetables and fish and drinks 1.5L of water a day. During Hospitalization During hospitalization his food and water intake was lessen. Analysis Nutrition is the sum of all interaction between organism and the food it consumes. (FON pg.1232) Defecation refers to the emptying of large intestines. Urination is emptying the urinary bladder. (Kozier and Erbs FON pg.1340) pg.1291) 3. Hygiene He takes a bath daily and brushed his teeth every after meal. He was not able to do hygienic practices so his family was the one who provides general hygiene for him. Cleanliness and grooming promote physical and psychiatric well-being. Improved personal hygiene practices reduce illness rates. Active exertion of muscles involving the contraction and relaxation of muscle group. Rest connotes a condition in which the body is in a decreased state of activity, with the consequent The client has slightly good hygiene. Interpretation The clients intake was lessen because of problem of hospitalization.

2. Elimination He experienced 5-6x urination and defecates once a day or six to seven times in one week.

His urine output is 30ml/hr. He defecates once a day.

The client has no problem when it comes to urination and defecation.

4.Exercise

He has no extraneous activities. From year 2000-2011 he was suffered from COPD and he has lack of exercise. The client sleeps 6-8 hours per day.

He doesnt have any exercise and is always lying in bed. But the relatives provide massage and stretching to his extremities. The client sleeps 6-7 hours per day.

He doesnt have enough exercises for his body.

5.Rest and Sleep

The client has a normal sleep pattern.

feeling of being refreshed. Sleep is a state of rest accompanied by altered consciousness and relative inactivity. The average amount of sleep required is 8 hrs. 6. Substance Abuse He consumes 1 pack of cigarette or 2030sticks a day and drinks alcoholic beverages occasionally. N/A Substance He has no substance abuse is a abuse during major threat to hospitalization. the health of young adult. Prolonged use can lead to physical and physiologic dependency and subsequent health problems.

VII. Physical Assessment Vital Signs

Measurements Blood Pressure Findings 110/70mmHg Normal Findings 90/60-120/80 mmHg 12-20cpm Interpretation Normal

Respiratory

27bpm

He is experiencing DOB and trying to compensate enough oxygen. Normal Normal

Pulse/Heart Rate Body Temperature

100bpm 36.5 C

60-100bpm 36.6C-37.5 C

Head to Toe Physical Assessment

Body Part Findings Norms Interpretation

Skin

Dry skin

Normally skin is a uniform whitish, pink or brown, depending on the clients race. No skin lesions should be present except for freckles, birthmarks or moles which may be flat or elevated. Skin should normally feel smooth, even, firm except where there is significant hair growth. A certain amount of roughness is normal. Normal skull is smooth, non-tender and without masses or depression. The scalp should be shiny, intact and without lesions or masses. Hair varies from dark black to pale brown. The shape of the face can be oval, round or slightly square. There should be no edema, disproportionate structures or involuntary movements. Should be smooth and uniform in consistency. Absence of nodules and masses. Both eyes should move smoothly and symmetrical. Eyebrows are symmetrical and evenly distributed above the eyelids. Evenly spaced along the lid margins and curve outward to protect the eye by filtering particles of dirt and dust from the external

Due old age

Skull

Smooth and non-tender

Normal

Scalp

No lesions and masses found

Normal

Hair Face

Dry hair, and the color is black to gray Around shape no nodules and masses

Normal Normal

Eyes Eyebrows

moves smoothly and symmetrical Symmetrical and evenly distributed above the eyelids Spaced along the lid margins and curve outward to protect the eye by filtering particles of dirt and dust from the external

Is in good condition Normal

Eyelashes

Normal

environment. Conjunctiva Sclera Shiny, moist pink in color Whitish in color with some superficial vessels Equally round and reactive to light and accommodation

environment. Shiny, moist, salmon pink in color Sclera should be white with some small, superficial vessels. Pupils equal round reactive to light and accommodation. Average pupil size 3-7 mm. EOM is intact; can move I 6 cardinal directions Able to see the fields, stimulus at about 60 superiorly, 90 temporally, 70 inferiorly and 50 nasally Good condition No deformities found Normal

Pupils

Eye Movements Peripheral Vision

Intact and can move 6 cardinal directions

In good condition

Visual Acuity

Able to see.

Able to see and read newspapers headline, by lines, detailed newsprint. Normal vision is 20/20 The shape of the external nose can vary greatly among individuals. Located symmetrically in the midline of the face and is without swelling, bleeding lesions and masses. Patent, clean and with a few cilia Septum is located midline The ears should match the flesh color of the rest of the body and should be positioned centrally and in proportion to the head. Cerumen should be moist and not obstruct the tympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions. The patient is able to repeat words whispered from a distance of 5 feet

Normal

Nose

Symmetry in the midline of the face, no swelling, bleeding , lesions and masses that found

No deformities

Internal nares Septum Ears

Clean with a few cilia Located in midline Match to the color of the body, centrally positioned and proportioned to head, no foreign bodies, deformities and lesions

Normal Normal Normal

Hearing Acuity

Can able to repeat words. ??

Lips

The lips and membranes pink, no inflammation or lesion Pale-red stipple surface, no bleeding or swelling found

The lips and membranes should be pink and moist with no evidence of inflammation or lesion In light-skinned individuals, the gums have a pale-red stipple surface. The gums should have no bleeding or swelling. 32 permanent teeth (adult) The dorsum of the tongue should be pink, moist, rough and without lesion. The tongue should be symmetrical and moves freely. Located at the floor of the mouth, interiorly, midline, moist

In a good condition

Gums

Is in good appearance

Teeth Tongue

Incomplete teeth Symmetry and moves freely, the color is slightly pink, moist, rough w/ lesion

Due to aging process Is in good condition

Frenulum

It locate to the floor of the mouth, is in the midline and moist Moist, smooth and free of lesion Can able to move from side to side and freely movable symmetrical from side to side

Normal

Buccal Mucosa

The buccal mucosa should Normal be moist, smooth and free of lesion. Able to move from side to side, freely movable Although no individual is absolutely symmetric in both hemispheres, most individual are reasonably similar form side to side. The normal depth of inspiration is non exaggerated and effortless Should have the same color, as the rest of the body, no presence of lesion, masses and tenderness, liver should not be palpable. Bowel sounds are usually high pitched occurring at 5-30 times/minute. ********* There are five fingers in each hand. Able to do ROM. Normal Good condition

Neck Thorax

Abdomen

Same color to the body, no presence of lesions, masses and tenderness. Absence of bowel sounds <5x/min.

Client has irregular defecation.

Upper Extremities Hands

******* Compete fingers in each hand and able to do ROM

******** Normal

Nails

Normally nails have pink cast. the capillary refill return to normal w/ in 2- 3 seconds

Normally, the nails have a pink cast for light-skinned individuals. The capillary refill may vary with age but color should return to normal within 2-3 seconds. ********* Knees are in alignment with each other. The foot is in alignment with the lower leg. The patient will be able to flex and extend the legs with no audible clicks will be heard during joint movement Normally, the nails have a pink cast for light-skinned individuals. The capillary refill may vary with age but color should return to normal within 2-3 seconds.

Due to her disease process

Lower Extremities Legs

******* Knees are in align and able to flex and extend the legs with no audible clicks will be heard during joint movement

******* Normal

Nails

The nails have pink cast capillary refill may vary color should return to normal w/in 2-3 seconds

Good condition

IX. Laboratory Findings/ Diagnostic Examination

Tests Hbg 8-26-11 133.4g/L Normal Findings 120 170 g/L Interpretations Normal

Hct

0.407

0.37 - 0.45

Normal

WBC MCV MCH MCHC

MPV 8 83.90 27.48 33

5.10 x 10 g/L 80-96 fl 27-31pg 33-36g/dl

Normal Normal Normal Normal

Neutrophils

0.778

0.54 - 0.75

increase

Lymphocyte

1.160

0.35 0.45

increase

Monocytes

0.048

0.01 0.06

normal

Eosinophils

0.011

0.01 0.04

normal

Thrombocytes

349

150 - 400

normal

glucose BUN Creatine Cholesterol LDL HDL Triglycerides

9.16mmol/L 4.52 85.52 5.53 3.80 1.14 1.31

4.10 5.90 2. 1 -7.1 53 106 Up 5.2 Up 2.47 0.78 2.21 0.68 1.88

increase increase normal increase increase normal normal

Sodium

8- 27-11 147.7 135- 148 normal

8-26-11 145.7 normal

XII. Anatomy and Physiology

Raises blood sugar

High blood sugar

Promote s insulin release

Glucagon Stimulates breakdown of glycogen

Glycogen-glucose

Insulin Stimulate formation of glycogen

Promote glucose release Lower blood sugar tissue cells low blood sugar

XIII. Pathophysiology (Flow Chart Format)

Modifiable

Obesity- 93kg BMI-34.96 Lifestyle-smoking, drinking liquor, sedentary Diet-high fat, cholesterol, CHO,CHON,

Non-modifiable

Age -49y/o

I
Poor production of Beta cells

Insulin Resistance

Impaired insulin secretions

Metabolic syndrome (Prevent build-up of glucose in the blood)

Intracellular: failure of glucose to enter in ICS

Intravascular: increase glucose in blood

Hypergylcemia (9.16mmol/L) Hypertension Hypercholesterolemia

Systemic blood Viscosity

Sluggish circulation
ECF/ICF dehydration

Cell Starvation Increase Osmotic pressure in renal tubules

Beta cells cannot keep up with the increase of glucose

Polydipsi a

Polyphagi a

Polyuria

Hyperglycemia

Diabetes Mellitus Type II

Scale for ranking health conditions and problems according to priorities

Hyperthermia
Criteria 1. Nature of the condition or problem presented Scale Wellness state Health deficit Health threat Foreseeable crisis 2. Modifiability of the condition or problem Scale : Easily modifiable Partially modifiable Not modifiable 3. Preventive potential Scale: High Moderate Low 4 .Salience Scale: A condition or problem needing immediate attention A condition or problem not needing immediate attention Not perceived as a problem or condition needing change Weight

3/3 x 1

1/2 x 2

3/3 x 1

2/2 x 1

ANSWER=5

Hypertension
1. Nature of the condition or problem presented Scale Wellness state Health deficit Health threat Foreseeable crisis 2. Modifiability of the condition or problem Scale : Easily modifiable Partially modifiable Not modifiable 3. Preventive potential Scale: High Moderate Low 4 .Salience Scale: A condition or problem needing immediate attention A condition or problem not needing immediate attention Not perceived as a problem or condition needing change

2/3 x 1

0.67

2/2 x 2

2/3 x 1

0.67

2/2 x 1

Answer = 3.34

Constipation
1. Nature of the condition or problem presented Scale Wellness state Health deficit Health threat Foreseeable crisis 2. Modifiability of the condition or problem Scale : Easily modifiable Partially modifiable Not modifiable 3. Preventive potential Scale: High Moderate Low 4 .Salience Scale: A condition or problem needing immediate attention A condition or problem not needing immediate attention Not perceived as a problem or condition needing change

2/3 x 1

1/2 x 2

2/3 x 1

0.67

1/2 x 1

0.5

Answer=3.17

XII. Prioritization of the Problems

Nursing Diagnosis#1: HYPERTHERMIA Interaction: mainitaangpakiramdamko Cues/Clues: ,skin is warm to touch, weak, irritable Nursing Diagnosis#2: HYPERTENSION Interaction: nahihiloaq at sumasakitangbatokko Cues/Clues:

BP=140/90 increased blood pressure

Nursing Diagnosis#3: CONSTIPATION Interaction: tatlongarawnasiyahindidumidumi Cues/Clues: Absence of bowel movement

Nursing Analysis Diagnosis Hyperthermia related to increased metabolic rate I mainit ang pakiramdam ko. O increase in body temperature -flushed skin -warm to touch M T -39.5 c BP- 140/100 Output 760 cc

Goal & Objectives Goal: After 8 hours of continuous intervention the clients temperature will be lessen or gain within normal range. Objectives: After 3 hours of rendering care, the client will state increased comfort, through either verbal reports or behavior

Nursing Intervention

Rat

Established rapport Maintained calm voice on Applied cold compress over the fore head. Monitor body temperature every 4 hours.

Performed tepid sponges bath. Advised the client to maintain adequate rest After 3 hours of health teachings the client and relatives will demonstrate the behavior in monitoring and promoting Discuss precipitating factors w/ patient if known

normothermia.

GENERIC NAME/BRAND NAME

CLASSIFICATION

ACTION

INDICATION

DOSAGE

PHENYTOIN

CNS drug

Limits seizure activity by stabilizesneuronal membranes of hyper excitable cells through decreasing influx of sodium during action potential

Tonic-clonic and psychomotor seizures

300g q12 x 3 doses

Si bl

RANITIDINE

GI drug

Inhibits histamine at h2 receptors site in the gastric parietal cells, which inhibits gastric secretion.

50 mg q8 IV Used in management of various GI disorders such as dyspepsia

hy

AMLODIPINE

Antihypertensive drug

Inhibits influx of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle, deceaseBP

Hypertension

10g 1tab OD

2n de

CEFTRIAXONE

Anti-effectives Inhibits bacterial cell wall synthesis, Treatment of

1g IV q12 (ANST)

Hy

rendering cell wall osmotically unstable, leading to cell death

susceptible infections

pe

CLINDAMYCIN

Anti-infective

Inhibits bacterial protein synthesis by binding the 50s subunit of the ribosomes

300mg 2tab QID Serious anaerobic infections,

Hy lin an im

MANNITOL

(fluid and electrolytes)

Increase the osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water & electrolyte & increase urinary output

Hy se 100cc q4 Reduction of increased intracranial pressure associated with cerebral edema

OMEPRAZOLE

GI drug

Suppress gastric secretion by inhibiting hydrogen/potassium ATpase enzyme system in the gastric parietal cell

40mg IV q12 Short term treatment of active duodenal ulcer, GERD

Hy co w sh pa im

ACETAZOLAMIDE

Cardiovascular drug

Inhibits carbonic anhydrase activity Adjunctive treatment of chronic simple(open angle) glaucoma & secondary glaucoma

250mg IV BID

Hy su el

CLONIDINE Cardiovascular drug Stimulates central alpha- adrenergic Management of all receptors to inhibit grades of sympathetic cardio hypertension accelerator& vasoconstrictor centers

750 mg SL

Hy clo

LOSARTAN Cardiovascular drug Selectively blocks the binding of angiotensin 2 to receptors sites in many tissue

100 mg 1tab OD

Hy Treatment of HPN

LACTULOSE GI drug Causes an influx of fluid in the intestinal tract by increasing the osmotic pressure within the intestinal lumen 300 OD HS

Pa lo

Constipation

Dexamethasone

Hormones & related drugs

4mg IV q 12 Synthetic glucorticoid with marked antiinflammatory Testing of adrenal corticol hyperfunction

Sy in

Ticlodipine Cardiovascular drugs Irreversibly inhibits ADP induced plateletfibrinogen binding & platelet-platelet interactions Reduction of risk of thrombotic stroke in patient who have experienced stroke precursors 750 mg tab TID

Pr he di

Paracetamol

Antipyretic, analgesic Decreases fever Relief of mild-tomoderate pain; treatment of fever

500 mg IV 300mg RTC

Hy al

Insulin Antidiabetic drugs Subcutaneous Decrease blood glucose Management of type 2 DM which cannot be controlled by diet ,exercise or weight reduction alone

Hy co ad in in

Diazepam

CNS drugs Facilitates, potentiates, the inhibitory activity of the CABA at the limbic system & reticular formation

STAT

Basal sedations before stressful therapeutic measures of intervention

Hy de su al